From: Subject: monografia Date: Mon, 5 Jan 2009 15:53:36 -0200 MIME-Version: 1.0 Content-Type: multipart/related; type="text/html"; boundary="----=_NextPart_000_0002_01C96F4D.C4CC5460" X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2900.3350 This is a multi-part message in MIME format. ------=_NextPart_000_0002_01C96F4D.C4CC5460 Content-Type: text/html; charset="iso-8859-1" Content-Transfer-Encoding: quoted-printable Content-Location: file://C:\Documents and Settings\Uti\Meus documentos\CUIDADOS PELE DO PREMATURO.htm monografia
Pediatria
 =20
=

Semin=E1rios
2001=

PELE DO=20 REC=C9M-NASCIDO PREMATURO

 Autora: Dr=AA.  Luciana Perrini=20 Hahn   -   Orientador: Prof. = Mitsuru=20 Miyaki

M=E9dica=20 Residente do Departamento de Pediatria do Hospital de Cl=EDnicas = da=20 U.F.Pr.
Monografia apresentada em Reuni=E3o = Departamental no=20 Departamento de Pediatria do Hospital de Cl=EDnicas

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A pele = atua como uma=20 interface entre o meio interno e o meio ambiente e oferece = fun=E7=F5es=20 especiais para a sobreviv=EAncia do ser humano.

Considerando = a import=E2ncia=20 deste tegumento como uma barreira contra infec=E7=E3o e sua = contribui=E7=E3o=20 no controle h=EDdrico e de temperatura, a prote=E7=E3o e a = preserva=E7=E3o da=20 pele dos rec=E9m nascidos s=E3o decisivas na sua boa=20 evolu=E7=E3o.


Em face = disso, foi proposto=20 um trabalho de revis=E3o intitulado A PELE DO REC=C9M = NASCIDO PREMATURO,=20 desenvolvido na disciplina de Neonatologia do Hospital de = Cl=EDnicas=20 da Universidade Federal do Paran=E1.

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Nos cuidados de=20 rec=E9m nascidos em unidades de terapia intensiva, torna-se = um desafio=20 manter a integridade da pele. =C9 de fundamental = import=E2ncia o extremo=20 cuidado com esta membrana, que representa, ao nascimento, = cerca de=20 treze por cento da superf=EDcie corporal, tendo em vista que = v=E1rios=20 procedimentos realizados na pele levam a quebra desta=20 barreira.

Nos rec=E9m = nascidos de=20 termo, a epiderme e os anexos cut=E2neos apresentam = desenvolvimento=20 completo, n=E3o havendo diferen=E7a na absor=E7=E3o = cut=E2nea da crian=E7a ou do=20 adulto. J=E1 os rec=E9m nascidos prematuros, principalmente = os abaixo de=20 32 semanas, possuem pele imatura incapaz de exercer seu = papel de=20 barreira, resultando em um aumento das perdas de =E1gua e = calor, bem=20 como, a absor=E7=E3o de toxinas do meio ambiente, = comprometendo defesas=20 antimicrobianas. Al=E9m disso, dispositivos de apoio =E0 = vida, coleta de=20 sangue e aplica=E7=E3o de subst=E2ncias t=F3picas, = proporcionam inj=FArias =E0=20 pele imatura, permitindo que parte significativa da=20 morbi-mortalidade desses rec=E9m nascidos possa ser = atribu=EDda a=20 pr=E1ticas inadequadas que provocam traumas ou = altera=E7=F5es na fun=E7=E3o=20 normal da pele.

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Rec=E9m = nascidos com peso de=20 nascimento e idade gestacionais cada vez mais baixos est=E3o = sobrevivendo com uma freq=FC=EAncia cada vez maior, face aos = avan=E7os=20 observados no manejo destes prematuros.

Atualmente na = Unidade de=20 Terapia Intensiva Neonatal do Hospital de Cl=EDnicas da = Universidade=20 Federal do Paran=E1, a sobrevida de rec=E9m nascidos com = peso de=20 nascimento abaixo de 1000g =E9 de 73,7%, entre 1000 e 1500g = permanece=20 em torno de 90% e acima de 1 quilo e meio a taxa de = sobrevida chega=20 a 98,3%. O trin=F4mio prematuridade, sepse e asfixia ainda = =E9 a maior=20 causa de =F3bitos nestes rec=E9m nascidos = prematuros.

Na literatura = pode-se=20 observar os seguintes dados:

Oitenta por = cento dos rec=E9m=20 nascidos que nascem prematuramente desenvolvem alguma = inj=FAria na=20 pele at=E9 o primeiro m=EAs de vida.

Aproximadamente 25% de=20 todos os prematuros de baixo peso, ter=E3o ao menos um = epis=F3dio de=20 sepse at=E9 o 3o. dia de vida, sendo a pele a = principal=20 porta de entrada.

Nos = pa=EDses em=20 desenvolvimento a preval=EAncia de sepse em rec=E9m nascidos = prematuros=20 =E9 de 30 a 60% com uma mortalidade de 40 a 70%, sendo a = septicemia a=20 principal causa de mortalidade.

No mundo, = aproximadamente=20 350.000 prematuros morrem em fun=E7=E3o de sepse e = meningite, sendo 50%=20 dos =F3bitos na primeira semana de vida, quando a fun=E7=E3o = de barreira=20 da epiderme est=E1 mais comprometida.

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Com o = objetivo de=20 analisar os cuidados fundamentais com a pele do prematuro = atrav=E9s de=20 uma atualiza=E7=E3o bibliogr=E1fica, rever o manuseio com a = pele na=20 Unidade de Terapia Intensiva Neonatal deste hospital, = minimizando=20 riscos de infec=E7=E3o, =E9 que foi realizada esta = revis=E3o.

Tem-se por = objetivo tamb=E9m,=20 propor atualiza=E7=F5es dentro da rotina estabelecida, = chamando a=20 aten=E7=E3o da necessidade de cuidados especiais em = prematuros,=20 possibilitando um melhor manejo no cuidado com a pele em = nossa=20 UTI.

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A = camada mais=20 externa da pele consiste em um estrato c=F3rneo, camada = bilamelar, que=20 funciona como uma barreira epid=E9rmica, composta por = lip=EDdios=20 hidrof=F3bicos, =E1cidos graxos, colesterol e ceramidas, = firmemente=20 aderidas entre si, que s=E3o cobertas por um envolt=F3rio = celular=20 cornificado rico em prote=EDna e queratina. O estrato = c=F3rneo =E9 formado=20 intra=FAtero no terceiro trimestre de gesta=E7=E3o. Sendo = assim, rec=E9m=20 nascidos prematuros, principalmente os que nascem antes de = 32=20 semanas de idade gestacional, possuem uma pele imatura que = =E9=20 ineficaz nas suas principais fun=E7=F5es.

A imaturidade = estrutural da=20 pele destes prematuros faz com que o extrato c=F3rneo e a = epiderme=20 apresentem uma camada mais "fina", com permeabilidade pouco=20 desenvolvida, causando mais perda de =E1gua pelo = insens=EDvel, aumento=20 da demanda cal=F3rica, perda de calor, aumento do potencial = de=20 absor=E7=E3o de toxinas, comprometendo assim sua fun=E7=E3o = de defesa contra=20 microorganismos.

A = matura=E7=E3o da pele=20 do RN prematuro normalmente acontece em 2 a 4 semanas, = podendo, no=20 entanto demorar at=E9 oito semanas nos grandes prematuros, = pois o=20 extrato c=F3rneo se desenvolve mais lentamente ap=F3s o = nascimento e=20 quanto menor for a idade = gestacional.

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A = pele apresenta=20 algumas fun=E7=F5es especiais, incluindo:

  1. modula=E7=E3o entre o fluxo=20 de =E1gua transepidermal, prote=E7=E3o contra a = desidrata=E7=E3o e o influxo=20 excessivo de =E1gua;

  2. termoregula=E7=E3o e=20 minimiza=E7=E3o das perdas de calor;

  3. defesa=20 antimicrobiana;

  4. prote=E7=E3o contra toxinas=20 do meio externo, trauma e radia=E7=E3o = ultravioleta;

  5. fun=E7=E3o de = sensa=E7=E3o=20 t=E1til

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Nestas duas=20 fotos, pode-se observar a diferen=E7a na pele de um rec=E9m = nascido de=20 termo e um prematuro. Observe a fina pele do beb=EA = prematuro em=20 compara=E7=E3o com a pele do beb=EA de termo e a facilidade = com que se=20 observa a vasculariza=E7=E3o sob a pele do RN=20 prematuro.

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Rec=E9m nascidos=20 prematuros apresentam alto risco de infec=E7=E3o devido =E0 = imaturidade=20 desta barreira, desordens na imunorregula=E7=E3o da pele e = decr=E9scimo da=20 fun=E7=E3o cati=F4nica. Nos prematuros, as numerosas = fibrilas, que=20 conectam a epiderme com a derme, s=E3o mais escassas e = largamente=20 espa=E7adas. Por isso os prematuros ficam mais vulner=E1veis = a bolhas e=20 tendem =E0 esfolia=E7=E3o da epiderme quando s=E3o removidos = adesivos, uma=20 vez que os adesivos podem estar mais firmemente aderidos a = epiderme=20 do que a pr=F3pria epiderme =E0 derme.

A = superf=EDcie cut=E2nea=20 tem um pH =E1cido que confere qualidades bactericidas contra = alguns=20 pat=F3genos e este pH =E1cido =E9 importante na defesa = contra infec=E7=E3o. O=20 pH da superf=EDcie cut=E2nea de uma pessoa normal =E9 = inferior a cinco. A=20 capacidade funcional da pele para firmar um manto =E1cido, = ou um pH=20 cut=E2neo inferior a cinco tamb=E9m difere com a idade = gestacional. No=20 neonato a termo, o pH imediatamente ap=F3s o nascimento =E9 = de 6,3, com=20 um decl=EDnio para 4,9 em 4 dias, ao passo que no rec=E9m = nascido=20 prematuro o pH m=E9dio =E9 de 6,7 ao nascer e de 5,0 somente = no=20 8o. dia de vida.

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As = pr=E1ticas de=20 cuidados com a pele realizadas diariamente nas UTIs = neonatais=20 incluem o banho, a lubrifica=E7=E3o com =F3leos emolientes, = o uso de=20 solu=E7=F5es cut=E2neas para antissepsia, fixa=E7=E3o de = adesivos para o apoio=20 =E0 vida e para os aparelhos de monitoriza=E7=E3o, = compressas adesivas=20 transparentes, e cuidados com a perda de =E1gua e com a = perda de=20 calor. Essas atividades podem causar traumas =E0 pele, = interrompendo=20 sua fun=E7=E3o de barreira.

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O = banho di=E1rio =E9=20 tradicionalmente dado a todos os pacientes, na UTI. As = finalidades=20 do banho ao nascimento s=E3o de remover os detritos = maternos, raz=F5es=20 est=E9ticas gerais e a redu=E7=E3o da coloniza=E7=E3o = microbiana. O banho, no=20 entanto, induz mudan=E7as na pele, principalmente no seu pH. =

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Em um estudo = de 1994, de=20 Peck e colaboradores, o banho do rec=E9m nascido com sab=E3o = alcalino,=20 aumentou o pH da pele em 2 pontos e meio e em mais de 75% = dos casos,=20 o pH demorou mais de 60 minutos para retornar ao valor = normal. Em=20 prematuros, este tempo pode durar at=E9 sete dias. =

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Al=E9m da = altera=E7=E3o do pH, o=20 banho remove o v=E9rnix, que tem fun=E7=E3o de prote=E7=E3o = contra o trauma,=20 hipotermia, infec=E7=E3o e cicatriza=E7=E3o de feridas. = N=E3o se sabe se o=20 v=E9rnix tem fun=E7=E3o bactericida. Sua principal = fun=E7=E3o =E9 de barreira=20 mec=E2nica. O v=E9rnix permite a hidrata=E7=E3o do extrato = c=F3rneo,=20 diminuindo a perda de =E1gua e de calor por=20 evapora=E7=E3o.

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O banho pode = causar=20 hipotermia, choro intenso, com tend=EAncia a aumentar o = consumo de=20 oxig=EAnio e distress respirat=F3rio e desestabilizar sinais = vitais.=20 Mudan=E7as nas propriedades de barreira da pele pode ocorrer = porque o=20 banho pode causar irrita=E7=E3o e trauma, principalmente se = o sab=E3o=20 usado n=E3o for apropriado.

Torna-se, = portanto,=20 desnecess=E1rio e at=E9 iatrog=EAnico banhar o rec=E9m = nascido,=20 especialmente o prematuro, imediatamente ap=F3s o = nascimento. Este=20 procedimento, se n=E3o for realizado corretamente, pode ser = mais=20 mal=E9fico do que ben=E9fico ao prematuro. =

Os = banhos com=20 hexaclorofeno, embora eficazes em reduzir a coloniza=E7=E3o = por cepas de=20 Staphylococcus aureus foram abandonados devido =E0 = toxicidade=20 pela sua absor=E7=E3o. O clorexidine, entretanto pode ser = uma boa=20 alternativa. Em muitos ber=E7=E1rios, para o primeiro banho, = =E9 usado=20 sab=E3o de clorexidine, que s=E3o eficazes para reduzir a = coloniza=E7=E3o=20 por um per=EDodo de at=E9 4 horas ap=F3s o banho. Embora = ocorra absor=E7=E3o=20 tanto em neonatos como em prematuros, ainda n=E3o foi = documentada a=20 sua toxicidade.

Na = pr=E1tica cl=EDnica,=20 muitas UTIs s=E3o relutantes em arriscar =E0 toxicidade, = ainda que=20 potencial, dos banhos antimicrobianos em prematuros muito = pequenos,=20 de modo que banhar ou n=E3o banhar =E9 pr=E1tica t=EDpica de = cada setor.=20

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O = estrato c=F3rneo da=20 pele do RN pr=E9 termo =E9 seco e apresenta reduzida = capacidade de=20 conter =E1gua, quando comparado com RN de termo e adultos e = sua=20 hidrata=E7=E3o =E9 de fundamental import=E2ncia. Estudos = preliminares=20 sugerem que a utiliza=E7=E3o t=F3pica de =F3leos pode trazer = benef=EDcio aos=20 rec=E9m nascidos de muito baixo peso ao proteger a = integridade do=20 extrato c=F3rneo e refor=E7ar a fun=E7=E3o da barreira = epid=E9rmica.=20

O uso de = =F3leos, tais como o=20 Petrolato, =F3leo de girassol e canola, como rotina nas UTIs = neonatais=20 tem aumentado desde um estudo piloto da Stanford University=20 envolvendo a aplica=E7=E3o de =F3leo duas vezes ao dia nas = primeiras duas=20 semanas de vida na pele de rec=E9m nascidos prematuros = abaixo de 33=20 semanas. Concluiu-se que estes prematuros apresentaram menos = epis=F3dios de piora cl=EDnica por sepse e menor = incid=EAncia de meningite=20 quando comparado com o grupo controle.

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Outro = estudo de=20 Wallace e colaboradores, publicado em 1998, compara a = efic=E1cia do=20 uso do mesmo =F3leo em prematuros abaixo de 1 quilo e meio = mostrando a=20 diminui=E7=E3o de infec=E7=F5es nosocomiais na raz=E3o de = 5,4/1000 comparado=20 com 12,7/1000 no grupo controle.


Os = lubrificantes=20 s=E3o usados tanto para rec=E9m nascidos a termo como para = prematuros. O=20 Aquafor =AE, =E9 livre de conservantes e cont=E9m petrolato, = =F3leo mineral,=20 cera mineral e lanolina. Os autores que preferem este =F3leo = mostram=20 que seu uso n=E3o est=E1 associado com efeitos nocivos = quando associado=20 com a fototerapia, protegendo a barreira epid=E9rmica e = n=E3o alterando=20 a flora cut=E2nea. Infelizmente este produto n=E3o =E9 = dispon=EDvel em nosso=20 meio.

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Um = estudo de 1996,=20 de Pretsley e colaboradores, verifica o potencial ben=E9fico = da=20 aplica=E7=E3o do =F3leo de girassol. Este potencial = inclui:

  1. diminui=E7=E3o da = incid=EAncia de=20 hipotermia;
  2. melhora da nutri=E7=E3o = atrav=E9s da=20 absor=E7=E3o percut=E2nea de lip=EDdios;
  3. melhora do desenvolvimento = neurol=F3gico, promovendo o contato m=E3e-beb=EA pelo = est=EDmulo t=E1til da=20 aplica=E7=E3o;
  4. normaliza perda de =E1gua=20 transepid=E9rmica;
  5. aumento da hidrata=E7=E3o = da pele e=20 diminui=E7=E3o de infec=E7=F5es em prematuros. =

A = maturidade da pele=20 determina o grau de absor=E7=E3o percut=E2nea. A pele do = prematuro,=20 principalmente a pele comprometida facilita a absor=E7=E3o = de=20 subst=E2ncias, que em outras situa=E7=F5es n=E3o causaria=20 toxicidade

A = descontamina=E7=E3o da pele=20 antes de procedimentos invasivos =E9 pr=E1tica comum nas = UTIs neonatais.=20 A coloniza=E7=E3o da pele =E9 importante fator de risco para = infec=E7=E3o=20 sist=EAmica, principalmente por staphylococcus, o agente = mais comum de=20 sepse em rec=E9m nascidos prematuros.

Uma = boa op=E7=E3o com um=20 amplo espectro de antissepsia da pele antes de procedimentos = invasivos parece ser o clorexidine. O clorexidine a meio por = cento=20 em combina=E7=E3o com o =E1lcool isopropil a setenta por = cento foi=20 equivalente ao uso de polvidine-iodo a dez por cento na=20 esteriliza=E7=E3o da pele de rec=E9m nascidos prematuros. O = uso de=20 clorexidine tamb=E9m foi superior ao polvidine-iodo na = redu=E7=E3o do=20 risco de coloniza=E7=E3o por cat=E9ter perif=E9rico em = neonatos. Nenhum=20 efeito t=F3xico tem sido associado ao uso isolado do = clorexidine,=20 entretanto absor=E7=E3o sist=EAmica pode ocorrer com a = solu=E7=E3o incluindo o=20 =E1lcool, sugerindo que =E9 melhor usar o clorexidine=20 isolado.

A = exposi=E7=E3o =E0 pele=20 ao polvidine-iodo tem sido associada a necrose e alta taxa = de iodo=20 s=E9rico na urina, causando hipotiroxinemia e at=E9 = hipotiroidismo. N=E3o=20 =E9 usado em rec=E9m nascidos prematuros.

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O = =E1lcool quando=20 usado na pele pode causar necrose, pois =E9 altamente = absorvido e=20 potencialmente t=F3xico. Em um relato de caso foi descrita = uma necrose=20 cut=E2nea hemorr=E1gica severa a n=EDveis t=F3xicos de = =E1lcool no sangue de=20 um neonato de 27 semanas gestacionais, quando a crian=E7a = foi=20 preparada com =E1lcool para cateteriza=E7=E3o umbilical e = depois deixada a=20 fralda saturada de =E1lcool em contato direto com a = pele.

Essa foto = mostra a=20 prepara=E7=E3o da pele com =E1lcool a setenta por cento para = pun=E7=E3o=20 arterial, pr=E1tica di=E1ria nos servi=E7os de terapia = intensiva, para=20 coleta de sangue para exames. Deve-se tomar o cuidado de = passar o=20 algod=E3o somente umidecido e n=E3o encharcado em =E1lcool, = para evitar=20 aplica=E7=E3o em excesso. Al=E9m disso, ao preparar a pele = para pun=E7=E3o com=20 solu=E7=F5es cut=E2neas, o ideal =E9 remove-lo com =E1gua = est=E9ril, diminuindo=20 assim os efeitos mal=E9ficos do uso dessas=20 subst=E2ncias.

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Em prematuros = =E9 freq=FCente=20 observar o efeito traum=E1tico da remo=E7=E3o de adesivos, = que inclui=20 abras=E3o da pele, eritemas e ulcera=E7=F5es. Estes, por sua = vez, causam a=20 redu=E7=E3o da fun=E7=E3o de barreira, o aumento da perda = transepid=E9rmica de=20 =E1gua e aumento da permeabilidade da pele.

Neste slide = pode-se ver a=20 les=E3o causada pela retirada de micropore usado para manter = o=20 ox=EDmetro em contato com a pele e as les=F5es de pele = causadas por=20 in=FAmeras pun=E7=F5es arteriais.

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Estes dois=20 diapositivos mostram a mesma les=F5es em regi=E3o anterior = no p=E9 direito=20 e esquerdo do mesmo rec=E9m nascido, em per=EDodos = diferentes, antes do=20 in=EDcio da terap=EAutica e ap=F3s a = cicatriza=E7=E3o.

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Aqui = pode se ver=20 les=F5es causadas por retirada de micropores que continham = talas para=20 manter acesso e pun=E7=F5es arteriais.

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Cuidados na=20 utiliza=E7=E3o destes materiais devem ser realizados, tais=20 como:

  1. limitar o uso de adesivos = na pele para=20 o estritamente necess=E1rio;=20
  2. remover eletrodos somente = na certeza=20 de que estes n=E3o ser=E3o mais necess=E1rios;=20
  3. usar um produto que sirva = de barreira=20 entre a pele e o adesivo quando for necess=E1rio fixar = c=E2nulas,=20 cateteres ou coletores;=20
  4. usar gel nos = eletrodos;=20
  5. utilizar faixas de espuma = como=20 substitutos de adesivos para posicionar eletrodos;=20
  6. cotonetes com =E1gua = est=E9ril podem ser=20 usados na remover adesivos;=20
  7. utilizar algod=E3o ou gaze = em=20 esparadrapos para imobiliza=E7=E3o de membros = puncionados=20

Este slide = mostra a=20 utiliza=E7=E3o de algod=E3o sobre o esparadrapo antes de = fix=E1-lo =E0=20 pele.

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Nas = UTIs neonatais=20 vem sendo usado =F3leo para a remo=E7=E3o de adesivos. Nos = eletrodos=20 cardiorrespirat=F3rios de prematuros =E9 utilizado um tipo = de barreira=20 cut=E2nea feito de pectina e metilcelulose. Em uma = avalia=E7=E3o=20 sistem=E1tica feita com o uso deste produto, somente 9 casos = de=20 escoria=E7=F5es foram visualmente notadas em 199 = observa=E7=F5es sobre=20 aplica=E7=F5es e remo=E7=F5es em 45 prematuros com peso = m=E9dio de 1570g e=20 idade m=E9dia de 7 dias. Este m=E9todo tem sido usado em = muitas UTIs com=20 excelentes resultados em termos de redu=E7=E3o do trauma da=20 pele.

V=E1rios produtos=20 podem ser usados no local da pele comprometida. =D3leos a = base de=20 petrolato proporcionam uma cobertura semioclusiva promovendo = uma=20 migra=E7=E3o de queratin=F3citos para o interior da matriz = da ferida.=20 Produtos que combinam =F3leo mineral, cera mineral e cera = artificial=20 com petrolato, como o Aquafor =AE ou a bacitracina t=EAm = sido largamente=20 usados pelo seu potencial cicatrizante.

Produtos como=20 hidrogel ou hidrocol=F3ide, proporcionam uma camada = epitelial que=20 previne o trauma na pele fr=E1gil do prematuro, promovendo=20 reepitaliza=E7=E3o e cicatriza=E7=E3o da pele do prematuro. =

Cremes = transparentes=20 permitem uma melhor visualiza=E7=E3o da ferida, s=E3o = semiperme=E1veis,=20 permitindo alguma passagem de =E1gua e oxig=EAnio. S=E3o = largamente usados=20 em prematuros em UTIs neonatais.

 3D"wpe1B.jpg

3D"wpe38.jpg

 3D"wpe39.jpg

Nessa = duas fotos,=20 v=EA-se a les=E3o extensa causada ap=F3s a retirada de = esparadrapos que=20 mantinham o cateterismo umbilical e a evolu=E7=E3o ap=F3s 5 = dias da=20 terap=EAutica com =F3leo estabelecida.

3D"wpe1C.jpg

 3D"wpe3A.jpg

A = perda de =E1gua=20 transepidermal ocorre em fun=E7=E3o de diversos = par=E2metros, incluindo a=20 umidade do ambiente e temperatura, idade gestacional e idade = p=F3s-natal, estado geral do rec=E9m nascido e temperatura = do corpo do=20 paciente. Em prematuros de menos de 1 kg, com idade = gestacional=20 inferior a 30 semanas, a perda de =E1gua transepidermal pode = variar de=20 80 a 200 ml/kg/dia. A perda por evapora=E7=E3o =E9 a = principal causa de=20 perda de calor em prematuros.

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 3D"wpe3C.jpg

Estes dois = diapositivos nos=20 mostram um prematuro logo ap=F3s o nascimento e sua = admiss=E3o na UTI e=20 ap=F3s 48 hs de vida quando houve intensa perda de =E1gua e = redu=E7=E3o no=20 seu peso inicial.

3D"wpe1D.jpg


A = morbidade e o=20 aumento da mortalidade causada por essas perdas tem obrigado = o=20 desenvolvimento de estrat=E9gias para a diminui=E7=E3o da = perda de =E1gua e=20 calor.


Estas = estrat=E9gias=20 incluem:

  1. manter o RN em incubadora = de parede=20 dupla;=20
  2. aumentar a umidade do = ambiente;=20
  3. usar adesivos = transparentes ou =F3leos=20 emolientes;=20
  4. usar pl=E1sticos para a = conten=E7=E3o de=20 calor quando o prematuro permanecer em ber=E7o de calor=20 radiante;=20
  5. aumentar o contato pele a=20 pele

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 3D"wpe3E.jpg

Aqui = podemos ver o uso=20 do pl=E1stico em ber=E7o de calor radiante para a = conten=E7=E3o de=20 calor.

Neste slide = pode-se ver a=20 encubadora de parede dupla usada em nossa UTI Neonatal com o = aparelho de umidifica=E7=E3o para manter a umidade desejada = do ambiente=20 dentro da encubadora.

Um = estudo publicado=20 na Clinical Perinatology em 1995 mostra que a perda de = =E1gua em=20 prematuros de muito baixo peso em um ambiente com 85% a 95% = de=20 umidade =E9 de apenas 10% da que ele perderia se estivesse = em um=20 ambiente umidificado a 50% e de apenas 5% da que ele = perderia em um=20 ambiente com 20% de umidade, mostrando a import=E2ncia do = uso do=20 umidificador na preven=E7=E3o da perda de =E1gua e da perda = de=20 calor.

 3D"wpe1E.jpg
3D"wpe1F.jpg

Rec=E9m = nascidos prematuros=20 quando comparados com rec=E9m nascidos de termo apresentam = uma perda=20 de =E1gua transepid=E9rmica duas vezes maior, podendo = significar uma=20 perda de peso em 24 horas de at=E9 30% do seu peso de = nascimento,=20 aumentando significamente a morbidade destes prematuros em = virtude=20 de desidrata=E7=E3o, hipotens=E3o, da ocorr=EAncia de = dist=FArbios=20 hidroeletrol=EDticos, especialmente hipernatremia, = instabilidade=20 t=E9rmica e aumento das demandas cal=F3ricas decorrentes das = perdas=20 evaporativas.

Estudos = mostram que a perda=20 de =E1gua =E9 maior quando o prematuro encontra-se sob calor = radiante do=20 que em encubadora, mesmo quando h=E1 prote=E7=E3o contra = perda de=20 calor.

3D"wpe20.jpg 3D"wpe3F.jpg

O uso = de uma=20 cobertura de pl=E1stico de polietileno sobre o beb=EA, reduz = o consumo=20 de oxig=EAnio e a perda de =E1gua. Uma cobertura pl=E1stica = sobre o t=F3rax=20 e sobre extremidades parece ser =FAtil imediatamente ap=F3s = o=20 nascimento, ainda na sala de parto, para preservar o calor,=20 aumentando a sobrevida de RN nascidos com menos de 28 = semanas de=20 gesta=E7=E3o.

Um estudo = sobre os efeitos=20 do uso do pl=E1stico de polietileno envolvendo o rec=E9m = nascido=20 imediatamente ap=F3s o nascimento oi realizado por Vohra e=20 colaboradores em 1999. O pl=E1stico foi envolvido = imediatamente ap=F3s o=20 nascimento, e apenas a cabe=E7a n=E3o era envolta. A = temperatura retal=20 foi mensurada com um term=F4metro digital antes e uma hora = ap=F3s o uso=20 do pl=E1stico. Concluiu-se que o uso do pl=E1stico aumentou = a=20 temperatura corporal em 1,54 graus Celsius, e essa = diferen=E7a foi=20 significativa. N=E3o ocorreu nenhum efeito adverso como = hipertermia,=20 infec=E7=E3o ou macera=E7=E3o da pele pelo seu uso. = Conclui-se que o uso do=20 pl=E1stico de polietileno imediatamente ap=F3s o nascimento = de=20 prematuros abaixo de 32 semanas reduz a perda de calor=20 significativamente, sendo este um m=E9todo barato, pr=E1tico = e f=E1cil de=20 ser realizado n=E3o interferindo no manejo do rec=E9m = nascido nem nas=20 manobras de ressuscita=E7=E3o, prevenindo assim a morte por = hipotermia=20 neonatal.

3D"wpe21.jpg 3D"wpe40.jpg

O = m=E9todo beb=EA=20 canguru =E9 uma alternativa para preservar o calor, = estimular a=20 amamenta=E7=E3o ao seio, promover o crescimento, diminuir o = n=FAmero de=20 dias de internamento, reduzir infec=E7=F5es e aumentar a = taxa de=20 sobrevida de alguns prematuros.


O = cuidado com a=20 pele tem sido alvo de estudos recentes e a taxa de = mortalidade tem=20 apresentado um excelente decr=E9scimo em todo o mundo. At=E9 = alguns anos=20 atr=E1s s=F3 sobreviviam prematuros que nasciam acima de = 700g, hoje j=E1=20 pode se falar em sobrevida, inclusive em nosso servi=E7o, de = prematuros de aproximadamente 500 gramas ao nascimento. =

Estrat=E9gias t=EAm = sido realizadas,=20 com o objetivo de manter a integridade da pele, para tanto, = h=E1 uma=20 necessidade de padroniza=E7=E3o nos cuidados de rotina em = nossa UTI,=20 especialmente quanto a aplica=E7=E3o rotineira de =F3leo, na = prote=E7=E3o da=20 pele do rec=E9m nascido prematuro. Torna-se fundamental, a = realiza=E7=E3o=20 de estudos que verifiquem a efic=E1cia do =F3leo, utilizando = uma=20 metodologia de score de integridade da pele, para validar = este=20 procedimento.

Sugerimos a=20 implanta=E7=E3o de um protocolo de pesquisa, que permitir=E1 = uma melhor=20 avalia=E7=E3o do que =E9 realizado em nossa UTI e das = medidas que podem=20 ser alteradas a partir desta visita.

3D"wpe22.jpg
3D"wpe41.jpg



A = prote=E7=E3o e a=20 preserva=E7=E3o da pele desses rec=E9m nascidos s=E3o um = importante passo=20 para a sa=FAde neonatal, ao permitir que essas crian=E7as = que vieram ao=20 mundo prematuramente apresentem uma melhor qualidade de = vida, com=20 menos chance de desenvolver altera=E7=F5es conseq=FCentes a = uma pr=E1tica=20 simples no manuseio com a=20 = pele.

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Voltar ao=20 in=EDcio =
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